Embodied integration: reflections on Mindfulness Based
Cognitive Therapy (MBCT) and a case for Mindfulness Based Existential
Therapy (MBET). A single case illustration.

Abstract:

In an earlier paper (Nanda, 2009), I put forth the argument that
the practice of mindfulness gives rise to existential-phenomenological
themes and that both practices of Mindfulness and Existential therapy
have many parallels. This paper explores how
existential-phenomenological themes inevitably arise in Mindfulness
Based Cognitive Therapy (MBCT), one of the models of 'third wave
CBT' when it includes a dedicated Mindfulness based practice for
MBCT therapists. In moving from the 'doing mode' of fixing
problems, to the 'being mode' of staying with experience,
MBCT's research in the prevention of relapse of depression for
people suffering from chronic depression offers insights into the
therapeutic aspect of mindfulness. This paper seeks to explore how
insights from Mindfulness Based Cognitive Therapy and Existential
Therapy may come together through an illustration with a case study. It
also highlights that the integration of theoretical therapy models
happens within the embodied 'being' of the therapist, rather
than remaining within the pages of textbooks. I call this embodied
integration Mindfulness Based Existential Therapy (MBET).

With the introduction of mindfulness, Cognitive Behavioural Therapy
(CBT) evolved into its 'third wave'--the first and second wave
being Behavioural Therapy and Cognitive Behavioural Therapy
respectively. 'Third wave' CBT therapies like Acceptance and
Commitment Therapy (ACT) by Steven Hayes, Dialectical Behavioural
Therapy (DBT) by Marsha Linehan, and Mindfulness Based Cognitive Therapy
(MBCT) by Segal et al. (2002) all emphasise the 'being mode'
of mindfulness. This paper focuses exclusively on MBCT and its rationale
for utilising mindfulness for the prevention of relapse of depression.

While CBT and interpersonal therapy were considered the gold
standard for treatment of depression as their efficacy was as good as
anti- depressant medication (Williams, 1992 in Segal et al., 2002), they
were not addressing the high levels of relapse/recurrence of depression
(Segal et al., 2002). Segal et al. (2002) highlight that formidable in
its implications was that those with two or more past episodes of
depression had a 70-80% chance of recurrence of depression in the future
(Consensus Development Panel, 1985 in ibid.). This meant the focus of
treating depression also required looking at risk of relapse of patients
being treated. The huge difference in risk of relapse between first time
depression with no past history (22%), and those with at least three
previous episodes of depression (67%) (drawing from Keller, in Segal et
al., 2002) showed that one of the most reliable predictors of relapse is
the number of previous episodes of depression. As Segal et al., (2002)
point out, the scope of the problem had changed from treating depression
to including prevention of relapse of depression.

In introducing Mindfulness for the prevention of relapse of
depression, Mindfulness Based Cognitive Therapy (MBCT) challenged
CBT's own fundamental assumption that negative dysfunctional
thinking needs to be got rid of and replaced with positive functional
thinking to combat relapse of depression. Rather, it embraced the stance
of the practice of Mindfulness of 'being with' experience
(Segal et al. 2002).

Some common attitudes that are valued in Mindfulness, MBCT, and
Existential therapy (used synonymously with existential-phenomenological
therapy) are the stance of a beginner's mind, openness to discover,
allowing experience to be disclosed, suspending judgment, non-striving,
letting go of any agenda of curing, fixing. All these approaches
encourage 'being with' experience, and an acceptance of what
is present.

Though CBT lies within the mode of 'doing',
'fixing' and 'getting rid of a problem', and
Existential therapy's focus is on 'being with
experience', Milton and Corrie (2000) have previously looked at
commonalities between CBT and Existential therapy, and how each therapy
may be able to learn from the other. They especially point out the
common areas around disclosing meaning through Socratic questioning and
emphasise the importance of the phenomenological attitude of the
therapist rather than the therapist privileging theory whether it is
Existential theory or CBT theory.

The following sections will look at the emerging phenomenological
attitude in MBCT as it moves from CBT's 'doing mode' to
MBCT's 'being mode', the theoretical basis of how
mindfulness within CBT helps in the prevention of relapse of depression,
and the rationale of the introduction of Mindfulness in my approach to
Existential therapy through a case illustration.

MBCT as 'Third Wave CBT' and the Arising of a
Phenomenological Stance

Mindfulness Based Cognitive Therapy (MBCT) is based on the
Mindfulness Based Stress Reduction (MBSR) model. Pioneered by Jon
Kabat-Zinn (at the Centre for Mindfulness at UMass Medical School more
than thirty years ago), MBSR was being utilized as an intervention to
help people suffering from various chronic physical illnesses and its
related emotional stress. MBCT like MBSR is offered in a group setting
over eight weeks (minus the full day of practice of MBSR). MBCT also
adapts the MBSR model to integrate some aspects of CBT in terms of
client education on depression. Both MBSR and MBCT offer the cultivation
of a radically different attitude. Instead of looking for ways in which
to fix the difficult problems, patients are encouraged to stay moment by
moment with their difficult emotions. For it is recognized that the
implicit assumption in fixing problems is that problems are the enemy
and that once problems go away, everything will be fine (Segal et al.
2002). Mindfulness practice offers a new perspective in which patients
who are trying to get rid of the difficulties they are experiencing,
have a chance to see what it feels like to let go of the desire to fix
problems, and how it feels to be in a place of non-reactivity, while
bringing kindly awareness to their difficult experience. The practice of
mindfulness also brings awareness that trying to fight against unwanted
thoughts, feelings, emotions, and body sensations creates more tension,
and conflict. Kabat-Zinn's (2005) definition of mindfulness
involves four aspects. It is paying attention, on purpose, in the
present, and non-judgmentally. Non-judgmentally is meant as acceptance
of what is present.

As Existential therapists, we may recognize how mindfulness
practice offers the cultivation of a stance more congruent with the
existential-phenomenological stance of 'being with' lived
experience, (both of self and that of the client) and being open to and
accepting what shows itself to us, moving closer to a stance of
authenticity. Spinelli notes, 'Heidegger intended authenticity to
refer to the opening-up to, or ownership of that which presents itself
to us.' (Spinelli, 2007 drawing from Cohn, 2002, pg 50). It offers
the opportunity of moving towards integration of experience as opposed
to pushing away experience or being dis-associated with our experience.
As Kabat-zinn (2005) and Segal, et al.,(2002.) note, it opens us to the
possibility of our freedom of responding with choice rather than from a
place of reactiveness. In MBSR/MBCT we can see the emergence of the
existential themes of the givens of our suffering, freedom and choice
within the givens.

As Mindfulness practice encourages looking at all experience,
irrespective of whether the experience is positive or negative, and
regardless of its importance, for whatever emerges is considered worthy
of attention, this stance is congruent with what Spinelli (2005) drawing
from Husserl describes as the phenomenological stance of
horizontalisation. With the introduction of mindfulness, MBCT without
realizing it explicitly has moved closer to the attitude of
horizontalisation utilized in the phenomenological method of enquiry.
Similarly, MBCT encourages moving away from analysing experience, to
noticing what emerges, thus encouraging the phenomenological stance of
description rather than offering explanations. Further, in staying with
noticing what is present, instead of focussing on the conceptual aspects
of what the experience should be, what is expected, what should be got
rid of, the mindful stance in MBCT is concerned with connecting with
what the experience is, which also facilitates another rule of the
phenomenological method of enquiry cultivating the attitude towards
epoche, noticing our assumptions of what something should be and
temporarily setting them aside or bracketing them.

As we have seen, in introducing mindfulness, MBCT has adopted the
phenomenological stance of curiosity, openness, clearing a space to be
present for what shows itself, and the phenomenological method of
enquiry--the rules of horizontalisation, description, and epoche.

Further the recognition of the relational stance of the
inseparability of body/mind another central assumption in
existential-phenomenological thinking stands disclosed in mindfulness
practice. In the practice of MBCT, Segal et al. (2002) note that
mindfulness practice, in bringing a body focussed awareness to our
emotional and cognitive experience, brings awareness that thoughts,
emotions, and feelings all have sensory correlates felt in the body.
This has particular relevance to the prevention of relapse of recurrent
episodes of depression. Segal et al. (2002) assert that as sensory
knowing is quicker than intellectual knowing (Gendlin (2003) would agree
that felt sense is pre-conceptual), mindfulness also facilitates an
early warning signal of mood disturbance, so it can be addressed before
mood rapidly spirals downward. The awareness of the breath in the body
is cultivated as an anchor, to steady oneself if looking at experience
feels overwhelming. This facilitates cultivating the ability to stay
with difficult emotions, a stance valued in existential therapy.

How Mindfulness helps in the Prevention of Relapse of Depression

In CBT treatment for depression, Segal et al. (2002) note that
though the dysfunctional attitude scale measured success in the
treatment of depression; what these measures did not show was that when
the mood for those who had recovered from depression was lowered only
slightly, it triggered high levels of dysfunctional thinking (themes of
loss, failure, and worthlessness). It was not only that dysfunctional
thinking was causing depression, but also the other way round, that sad
mood could reawaken dysfunctional thinking (Segal et al., 2002). Sad
mood was the context through which the self and world were being
experienced. I see this similar to Heidegger's (1962) stance on
mood as 'attunement' as the dominant lens or context through
which we see and experience the world.

This tendency to react to small increases in sad mood with large
changes in negative thinking--'cognitive reactivity'--seemed
to be the crucial aspect that needed addressing to prevent relapse and
recurrence of depression (Segal et al., 2002).

Importantly, neurobiological research suggested that every new
episode of depression contributed to small changes in the
neurobiological threshold at which depression is triggered, thus
lowering the threshold. It seemed that depression was leaving a mark on
people even when they got well leaving them still vulnerable to '
cognitive reactivity' (ibid.).

Further, (Nolen-Hoeksema, 1991 in Segal et al. 2002) pointed out
that repeated analysis and efforts to problem solve one's way out
of depression, by going over the same event or situation repeatedly and
ruminating on it only increased depressive mood. A vicious cycle
resulted. Depressive thinking and rumination increased sad mood. And sad
mood increased ruminations and habitual negative patterns of thinking.
This set up a self-perpetuating vicious cycle leading to disabling and
severe depression.

Introducing Mindfulness: As a practice of 'decentering'
with a difference

CBT was utilising 'decentering' a metacognitive process
to help change the patient's relationship to their thoughts, to
stand back, 'distancing' themselves from thoughts and feelings
to evaluate their accuracy. Thoughts were seen not as objective truth or
reflecting aspects of self or objective reality, but rather thoughts
were just seen as thoughts. Decentering helped shift the patient's
perspective on negative thoughts and feelings. It was meant to protect
people from future depression. However, Cognitive therapy was using
decentering as a means to an end--for changing negative thinking to
positive thinking, and not as an end in itself (Segal et al., 2002).

Segal et al. (2002) utilised decentering with a difference, which
was the MBSR stance. Mindfulness practice offered a practice of standing
back not only from thoughts, but also from feelings, emotions, and body
sensations. It involved just noticing the emerging experience, but not
entering into the content of thoughts, or emotions, or offering
explanations, or trying to get rid of negative thinking. It offered the
'being mode'. As Segal et al. (ibid.) note, it helped to
create cognitive space in a mind which was constantly ruminating.
Instead of trying to replace negative thinking with positive thinking,
it offered the cultivation of an attitude which is curious, attentive,
interested, enquiring, accepting, and kindly in which harsh self
criticism can be just noticed as something 'I do' rather than
something 'I am' (Fennel, 2004). Thoughts are seen as passing
events in the mind, or as clouds passing in the sky of the mind. They
are seen not as 'valid reflections of reality nor central aspects
of the self' (Segal et al., 2002, p. 38). This stance moves closer
to the Existential-phenomenological stance, which questions notions of a
fixed or rigid self or objective reality.

Conscious aware practice to take space in 'limited capacity
channel' to stop rumination

Research in Cognitive therapy showed that if the limited capacity
channel of the mind can be filled up with non-ruminative material, for
that period rumination will cease. Mindfulness as a conscious aware form
of information processing fulfilled the requirement of taking up space
in a 'limited capacity channel' (Segal et al., 2002) in the
mind. Again by just noticing without analysing, it offered the
opportunity to step out of ruminations. In encouraging the cultivation
of the 'being mode', it offered patients possibilities and
choice on how to respond (ibid.)

Provide an early warning system

Being a body focussed practice, Mindfulness practice brings
awareness of the inter-connectedness of thoughts, feelings, and body
sensations. The somatic correlates of distress are felt quicker than
they become known intellectually. Thus these somatic correlates meet the
need of any early warning system, warning of an impending avalanche of
negative ruminative thinking, which could be nipped before it is too
late to stop.

CBT and MBCT recognise that depression is maintained by negative
self definitions which are seen as truth or reality, biases in noticing
information about self with a consistent negative lens and ignoring
information which is contrary to it, and ruminating on these (Fennel,
2004). However, Mindfulness offers a different perspective in adopting a
gentle, accepting, enquiring, kind, and compassionate way of relating to
what emerges in the body and mind, without any attempt to change it.

Segal et al. (2002, p 318) note that in introducing mindfulness to
patients suffering from three or more episodes of depression, 'MBCT
almost halved relapse/recurrence rates over follow up period compared to
treatment as usual.'

CBT, MBCT and Existential Therapy

One central assumption common to CBT, MBCT and Existential therapy
is challenging notions of a fixed and rigid self, and an objective
truth, or objective reality, and instead looking at the construction of
interpretations and emergent meanings. Another assumption which they
share is the interconnectedness of body/mind/world. CBT therapist
Padesky (1995) shows the CBT model of the interconnectedness of thought,
emotions, physical sensations, behaviour and life situation as being
interconnected. I see this similar to the interconnectedness of
body/mind/world, or self/other as expressed by Heidegger (1962) notion
of 'dasein' or being-in-the-world with others.

However, how therapy is carried out by these models of therapy is
different. While CBT subscribes to the 'doing mode', both MBCT
and Existential therapy subscribe to the 'being mode'. While
CBT and MBCT have structured protocols for specific problems, (albeit
CBT in 'doing mode' and MBCT in 'being mode' offered
in a group setting), the openness of Existential therapy lends itself to
a free flowing engagement and exploration. Looking at any one aspect of
the self opens up the enquiry to the whole of the self-construct. It is
not possible to separate the enquiry into different compartments of
problems, even though only one or some of them may be the presenting
issue.

Secondly, in Existential therapy there is no treatment plan, or
directed goal setting. It is recognised that the exploration may open up
areas that neither client nor therapist had anticipated. The stance of
not knowing, and an openness to discovery of the client's
being-in-the-world with others is far more textured, nuanced and subtle
than the direct goal setting, problem solving stance in CBT. MBCT, on
the other hand, in including Mindfulness encourages the beginner's
mind and openness to discovery coming closer to Existential therapy.
Even so, MBCT is couched within the medical model, after all MBSR was
pioneered in UMass Medical School by Kabat-Zinn. However, paradoxically
Kabat-Zinn's genius lay in speaking in the language of the medical
world, while healing the Cartesian divide by calling the MBSR programme
mind/body medicine! I see this as masterful and mindful. To be heard by
others, we need to speak their language.

Thirdly the therapeutic relationship in Existential therapy itself
is of primary importance. What therapists do in therapy is secondary to
how they can be in the therapeutic relationship. The structured nature
of CBT and MBCT (offered in group setting) do not have the same scope of
exploring the therapeutic relationship, though in MBCT (Segal et al.,
2002) recognise the importance of the therapist's own embodied way
of being will have an impact on the way MBCT is offered and its
effectiveness in conveying the 'being mode'.

Fourthly, Existential therapy has a whole dimension of exploring
the human condition and is grounded in philosophy. The recognition of
existential anxiety is a call to address the unease of life itself, to
look at meaninglessness in life, it asks to take courage, and how we may
take responsibility to construct meaning in our life. it recognises that
life has difficulties, and it moves away from pathologising human
suffering. In acknowledging and accepting the human condition, our
mortality, it recognises the dilemmas of life and living. We are
condemned to choose, our possibilities are available only within
limitations, and to take responsibility to give meaning, purpose, and
direction to our life (van Deurzen-smith, 1997, van Deurzen, 2005). This
indeed comes close to the existential-phenomenological themes within the
tradition of mindfulness as explored in my earlier paper (Nanda, 2009).

Mindfulness, MBCT, Existential Therapy: An Embodied Integration

As an Existential therapist, where do I stand in all of this?

I seem to have little difficulty in bringing together Mindfulness
and Existential therapy as a practice of Mindfulness Based Existential
Therapy (MBET). Both Mindfulness and Existential Therapy are part of me.
While I am a long term practitioner of meditation, my teacher training
in MBSR (at the Centre for Mindfulness, UMass Medical School, US) the
model on which MBCT is based offers me the skills for teaching
Mindfulness within groups. I draw from the seminal work by Segal et al.
(2002) on MBCT to inform me of how Mindfulness helps with the prevention
of relapse/recurrence of depression. I have no difficulty in adapting to
the needs of the situation flexibly, especially if I am introducing
Mindfulness to a therapy client.

For me the central aspect is an openness to enquiry, curiosity,
being with experience, attentiveness, a respectful space which is a
fundamental phenomenological stance in therapy, and an exploration of
the existential themes of the human condition. Mindfulness enhances this
for me, and from MBCT, I take the rationale for its introduction for the
prevention of relapse for depression

Illustration of Therapy with John

John came to see me for help with his depression, five months after
their baby was still-born in an advanced stage of his wife's
pregnancy. They have an older child. John was on antidepressants, but
even with the medication life was feeling much too hard to cope with.

Therapy before Introducing Mindfulness: The Unfolding of the
Therapeutic Relationship and Existential Themes

John spoke of his immense sorrow and loss at the death of their
child. As I listened attentively sharing the space, the silences, and
offering my understanding of his pain, what felt palpable for me was the
human to human connection we had. While I have never experienced loss of
this nature, I am no stranger to the human condition of pain and
suffering. Perhaps John sensed that I felt his pain with him.

In our second session, John expressed his grief not only of losing
his child, but also of the possibility of not being able to have another
child. His wife's history of difficult pregnancies and miscarriages
was painful. Yet, waiting much longer with the biological clock ticking
away for his wife at age 40 years seemed equally painful for him. He was
distraught. I acknowledged his distress and stayed with his experience.

His next statement came as a surprise, 'You must have had
other people come to you with similar issues. In your experience, what
do you think we should do, should we try for another baby?'

I realized John thought of me as an expert who could solve his
problem for him. He was confronted with existential issues. Death of
baby, time ticking away, loss, uncertainty about the outcome of another
pregnancy, anxiety, choice, and responsibility (Heidegger, 1962). The
disclosed existential themes revealed the dilemma of the human condition
in his personal predicament. The Existential-phenomenological approach
sees dilemmas as the human predicament, the difficulties of life and
living, and does not pathologize them. They are welcome, as they offer
possibilities for discovering meaning and purpose within the limitations
of life.

I replied, 'You are asking me to choose for you whether you
and your wife should try for another baby?'

John: 'What do you think?'

Jyoti: I can see it is a difficult situation, and choosing one way
or another is really hard. It is a real dilemma. I really don't
know what the right choice is for you John. What do you and your wife
want?'

John looked crestfallen.

John: 'That's not very helpful. If I knew I wouldn't
ask you.'

Jyoti: You're looking for an answer from me, and I am not
telling you what to do! (Pause) I can understand you are perhaps
disappointed and perhaps annoyed with me. But you are assuming that I
should know what the right choice is for you.

John looked perplexed and thoughtful.

Jyoti: (Silence) 'Perhaps the answer will emerge, as we find
greater clarity about what is really important for you.'

Over the course of therapy, my feeling comfortable with the not
knowing, and moving away from being the expert who knows the
'right' answers from the 'wrong' ones and someone
who provides explanations of what is 'wrong' and knows how to
fix it, perhaps facilitated for John a greater comfort in staying with
his own not knowing, and uncertainty.

In subsequent sessions, this opened up another area of exploration,
'what' and 'how ' someone should be. For John
'normal' meant being like others, and having what others have.
This stance is similar to Heidegger's 'The They'
(Heidegger, 1962). To this extent, not having a second child felt to him
like a personal failure, especially when he saw others with two
children.

I empathized with him, 'It feels like a reminder yet again,
and of course it is painful. But I am not sure I understand why you see
this as personal failure'.

This opened up the exploration of the self-definition of being a
failure. It meant not being able to control outcomes.

Jyoti: 'Of course, you wish you could save your baby. So do I.
But I am still not sure I understand why you see this as personal
failure.'

John: 'It is pathetic, I feel helpless that as a father I
couldn't somehow save our baby'

Jyoti: (after a silence saying softly) 'Of course, it feels
helpless. Both of us wish it had been different. But can either of us
control outcomes in matters like birth and death, which are beyond our
control? Can either you or I know when and how we or our loved ones are
going to die?

The existential theme that we have choice only within the givens of
our human limitations (Heidegger, 1962) informed my intervention. I
acknowledged our shared desire for life, and our shared helplessness of
what is beyond our control- birth and death. This intervention was
possible within the strength and quality of our relationship. Without
the relationship itself, it could sound quite clinical. Our being
together with the pain and suffering of the human condition, sharing the
space and the silences allowed John to reflect and re-consider what was
beyond our control, that possibilities arise within limitations.

John looked forward to our meetings, and so did I. Though never
schooled in philosophy, John had a wonderful capacity for reflection,
which in turn encouraged me to explore. In our relationship, perhaps
John experienced care, kindness, empathy, respect, acceptance, warmth,
and the shared place of 'both', 'us' and
'we'. The implicit message I was conveying was that I could
accept John just as he was. Acceptance of his personhood did not prevent
me from challenging his 'sedimented' beliefs. Our relationship
could be seen close to Buber's I-Thou relationship. It offered
inclusion of John's way of being by me, while also confronting him
with my own being (Buber, 1958; Friedman, 1999).

Session after session, we explored existential themes in relation
to his lived experience. In exploring his self-definitions around
failing, John realized that as far back as he could remember he felt
this way. His father was domineering, and John had been given little
choice. His father had even chosen the profession in finance for him,
though he had wanted to be an artist. As John began to get in touch with
his feelings, he wanted to change his job and become an artist. We
explored the consequences of such a choice. John realized that though he
did not like his job, he liked his current life style. He decided that
he would stay, but with a difference, now he was choosing and that felt
better. He was recognizing that choice, consequences and responsibility
went together. The existential notion of time was also revealed that the
present contained the past as it looked towards the future (Heidegger,
1962). He needn't be a passive victim of his past. He could give
direction to his life.

At work, John recognized how the financial markets going up and
down affected his moods like a 'yoyo'. However, as we
explored, even here he began to realize he had choice.
Successful/unsuccessful deals need not be equated to self-definitions of
worth/worthlessness of his personhood, albeit that was how the work
place utilized language. John had choice in how he defined himself, and
these were valuable insights for him.

After twenty-four sessions over seven months into therapy, John
seemed to be already defining himself differently and less
self-critically. At work, he began to question his colleagues in
meetings. Earlier when he was questioned, he invariably believed that he
was at fault, and accepted criticism from others without questioning or
exploring it further. In his personal life, he began to stand up to his
father, and also started expressing his needs more freely to his wife.

In our relationship, I often felt admiration for John, for his
capacity for philosophical reflection, the silences in which I could
sense that he was actively recreating meaning for himself through our
dialogical encounter, for his openness to be forthcoming in wanting to
address his issues, and his ability to take back into his life what we
had discussed.

Revisiting the initial concern

It seemed that John was in a more robust place as compared to
before. However, there seemed to be a dramatic shift for him after his
baby's first death anniversary. The week before the death
anniversary, he seemed in a stable place, and yet the week following the
anniversary he said it felt like he was back in the same dark and
hopeless place as before. I acknowledged the sadness that he was
experiencing. He expressed concern about the dramatic mood swing that he
had experienced following the anniversary, and wondered if this was how
it was always going to be. He asked, was there nothing I could teach him
in terms of a 'method' that could help him to not slide back?

I knew that feeling sadness at an anniversary was not unknown, or
uncommon. Yet, the way John described his downward spiraling of mood, I
wondered if this was 'cognitive reactivity' triggered in sad
mood in the way that MBCT speaks of. Mood as context in MBCT resonates
with the Heideggerian notion of mood as 'Befindlichkeit' the
German term which 'designates our moods as ways of finding
ourselves in the world' (Polt, 1999, p64). Our experience of
reality is disclosed through the attunement of our moods. However,
drawing from Heidegger's 'Beingand Time', Polt notes that

not all moods are equally disclosive. Someone may be trapped in an
inauthentic or inappropriate mood. In this case, mood still shows
things, but it shows them in an overly restricted way. This is why we
need to gain some control over our moods (175/136). Our goal should not
be to escape from moods altogether, but to find the right moods. (One
wishes Heidegger had said more about how to do this.)

(Polt, 1999, p.66).

That MBCT recognized the importance of monitoring mood, and of
mindfulness in providing an early warning system of an impending
avalanche of a dark mood is noteworthy. My understanding of the '
right moods' (Polt, 1999) is one that opens and widens rather than
restricts disclosing. I believe that mindfulness is one such way that
could offer us this possibility of 'doing' which opens us to
our 'being'.

Here was John asking for a 'method' to re-orient his sad
mood. The 'method' that I could offer him was
'mindfulness'- one of being present to all his feelings,
thoughts, body sensations within his situational context in a spirit of
enquiring, welcoming and accepting.

Reflections on introducing mindfulness

I was aware that the Existential approach is technique averse. I
needn't have offered mindfulness. I could have stayed with
John's distress in the manner that I had, and clearly that was
helpful to John. Yet there was this whole body of research that I was
aware of. Should I deny John a practice that I believed would be
helpful?

What weighed for me in favor of offering Mindfulness to John was my
belief that mindfulness would offer him a skill, as it was body focused,
of detecting small sensory correlates of mood changes in the body before
the mood spiraled out of control, while something could still be done
about it. Reflection was already a part of our work together; a body
focused practice would be new.

As I did not in any way wish to reduce the time we had together for
our usual therapy session, I felt if I was to introduce mindfulness, it
would be as an add on. I recognized that this introduction would mean
the changing of many boundaries (not least that I would be mindfulness
teacher and therapist) and it would have an impact on the therapeutic
relationship, and on the process of therapy. There was also the
possibility that the practice of mindfulness might not go down well for
John. However, I felt that we had a strong enough relationship and John
could feel free to let me know if mindfulness was not for him. I also
believed in my own capacity to be open to hear John's displeasure
regarding it, were it to not suit him.

I spoke to John of Mindfulness and its efficacy in MBSR/MBCT. John
seemed enthusiastic to try out mindfulness. He said he trusted me and
would be happy to try it out. I was open and honest in disclosing that
it was the first time I was utilizing Mindfulness in a therapy session.
It also was an opportunity for him to choose whether to try it out or
not. I said that since this was my very first time of offering it to any
one in a therapy session, I too would be learning from it. I would not
charge him for the extra time of 30 minutes we spent on mindfulness
before the start of the session, as both of us were venturing out into
unchartered territory. At this John expressed satisfaction, and
gratitude.

This was to be a new phase in therapy.

Introducing mindfulness in the session

At the next session, I introduced body focussed mindfulness of the
breath to John. This involves noticing the body sensations associated
with breath and breathing. It is a practice for training attention and
focus, as well as recognizing every time a thought, feeling or emotion
arises, noticing them with acceptance, and coming back to the breath in
the body. This was a departure from how Mindfulness is introduced in
MBSR/MBCT, which introduces Mindful eating of a raisin, and the body
scan first. While MBSR and MBCT programmes require practice commitment
for a minimum of 45 minutes a day, I sensed that I would need to be
flexible with John. I asked him what he felt was a realistic amount of
time that he could put aside for a daily practice. John felt that he
could commit to ten minutes for a regular daily practice. I agreed to
what he was able to commit to with the view that gradually if he could
find more time, he could increase the duration to whatever felt
comfortable to him, but that he would stick to a baseline of ten minutes
of practice everyday. Before the end of the session when I asked him how
he had experienced the mindfulness practice, he said he felt relaxed in
the body, and felt calm.

The following week when we met, I was curious to know how he had
experienced the practice. I was expecting John to say, like many people
do, that it was hard to maintain focus, that he felt bored and sleepy.
However, John replied that he had found the practice very useful. It
gave him time to sit with himself, allow thoughts, feelings, emotions to
emerge, and that it felt such a relief not to have to fight with them to
get rid of them, that they could just be present and accepted. He also
found focusing on the breath calming and relaxing. I was surprised at
the way in which he described his experience, as though he was an
experienced mindfulness practitioner.

That he was commenting on the letting go of the conflict or
struggle of trying to get rid of difficult emotions, seemed to me to be
almost unbelievable. This in just ten minutes of daily practice over the
period of one week! I was somewhat awestruck by John's ability to
take this practice on board so seriously, albeit for ten minutes a day.

While the MBSR/MBCT programme introduces mindfulness of scanning
the whole body, mindful movement, and mindful walking, John expressed a
lack of interest in the body scan. The size of the room did not permit
the practice of mindful movement, and mindful walking, (though we
practiced mindful walking in the corridor, our usual path to enter and
leave the room, once on a day when I knew we would not make a spectacle
of ourselves!) So the main focus of our practice was on mindfulness of
breathing. This extra time of 30 minutes with Mindfulness continued for
nine weeks, before a vacation break. By the time it was time for the
break, John was practicing ten minutes of mindfulness regularly on a
daily basis. He reported that he felt that he was using his breath as an
anchor at times when he was feeling stressed at work, and in being with
his breath, he felt calmness. He also expressed that he felt a greater
clarity about the connectedness of his thoughts, emotions, feelings, and
body sensations. He could experience body correlates with thoughts, and
emotions, and locate the body sensations with the arising of thoughts,
and emotions. He also reported recognising how standing back just a
little bit from his thoughts enabled him to see thoughts as thoughts,
rather than as 'facts' or 'truth' or
'reality'. He was developing 'metacognitive
awareness' as described by MBCT therapists Segal et al. (2002). He
recognised how often he was 'constructing and imagining
scenarios' as though they were real, and reacting to these imagined
constructions.

At work, when things were getting too stressful with deadlines, he
could take a few moments just to connect with his breath, and create
some space in which to see things more clearly. Feeling the breath in
the body, feeling the body sensations of tightness of muscles in his
chest, associated with the anxiety, and dread of the situation, allowed
him the embodied experience of anxiety, and the understanding of the
inter-connectednes of how we think and construct meaning, with our
emotions, feelings and body sensations. With bringing awareness to the
body sensations of tightness of muscles, and staying with them, John was
able to ease the body tightness, and stress. Such moments of calmness in
the body and mind also enabled him to re-evaluate the situation of his
work. For John to have an embodied experience of the relational aspect
of the construction and definition of his 'self', and
'reality' felt freeing. John began to experience lightness in
everyday living.

John's newfound confidence seemed to be visible by the way in
which he walked, and how he carried himself in a more purposeful manner.
John said that despite the ups and downs, he felt able to embrace his
negative feelings. He was able to monitor when his own habitual self
critical stick showed up to beat him up. This meant that John now did
not automatically lead himself onto self-critical self-definitions.

Coming off antidepressant medication

About five months after the introduction of mindfulness, John asked
if I thought he could give up his anti-depressants, as he seemed to be
coping well. I asked him how he felt about giving up his medication, and
explored the implications of giving it up. John said he was feeling
competent at work, and things felt under control. I asked him to consult
his GP if he wanted to come off the medication. John got the go ahead
from his GP. However, it was another five months before he started
coming off the medication as he was head hunted for another job, and
this meant a stressful time of professional transition ahead.

John started tapering off the medication under supervision from the
GP. As the effect of the medication started waning, John reported
experiencing his feelings with greater intensity, with greater nuances
to them. The irritations and frustrations had greater intensity, but so
did the pleasures and the joys. Colours seemed more vivid, and sharper.
What he was noticing had a wider range to them. While he was still
coming off his medication, it was his baby's second death
anniversary. We had explored what it might mean for him, to come off his
medication at such a time. John felt alright about coming off his
medication despite the forthcoming anniversary. The week after the
anniversary, when we met, John reported that he had felt sad, but that
he had allowed the sadness to be present. He felt that in embracing his
sadness, he could also let go of it in a way that he had felt unable to
do so earlier. It was an intensely moving moment when he said,--'If
anything good has come from this death, it is this opportunity to
evaluate my life, in a way in which I would never have done.'

John came off his medication fully. Some months earlier, John had
expressed how much the practice of mindfulness had made a difference to
him. It was also the time when I was offering workshops on mindfulness
and asked him how he felt if I spoke about our work together on the
introduction of mindfulness in therapy, keeping the confidentiality of
course. John gave me written permission to speak or write about our work
together. He also offered to help in any way which might facilitate
furthering writing or research on this subject, and offered to write
about his experience.

After John had come off his medication, he asked me if I had
written about introducing mindfulness in therapy for publication. To his
query, when I said I had not yet written it, John felt free enough to
let me know that he was disappointed with me!

The client's Perspective

It is not often that we get a qualitative account of the
client's written perspective on the experience of therapy. For that
reason alone, it becomes worthwhile in offering it as a small
contribution to the body of research on Mindfulness in individual
therapy.

Here is John's experience in his own words:

'Dear Jyoti,

Mindfulness:

I remember quite clearly when you first made reference to
Mindfulness as an option that we might try: it was the week of the
anniversary of the birth/death of (baby's name).

With the work that we had done together over the preceding
six/seven months, I had been feeling happy and confident again. The
anniversary unexpectedly pulled me down again, and I can remember
expressing a frustration to you that I did not have a mechanism to deal
with such situations. I felt vulnerable again notwithstanding that I had
been feeling so much stronger--it was as though I was kidding myself,
and the grief could always come back and consume me if it wanted to.

Given the work we had done, I felt completely trusting of you,
which I think was important to me if I was to consider trying something
very different.

You positioned it very well- it was an option. There was no
pressure to try it, but it did appear it could provide me with
something--a tool, if you like, to allow me to help myself.

For me, the simplicity and naturalness of Mindfulness instantly
held appeal for me. The fact that it was a long standing technique that
had been developed in an American university to help people, gave it
credibility, and a sufficient sense of mainstream for me to consider it
both safe and workable.

The other key factor was your willingness to make additional time
available to learn the Mindfulness--it meant it could be done as a
supplement to the counselling which was important for me as it again
felt that this was a supplemental help rather than a replacement for the
counselling that had preceded and had helped me; it encouraged me that
you felt that it warranted time and effort to be learned; and the very
fact that you were offering to make more time available without seeking
additional payment sent a very encouraging message to me. It felt as
though you were tailoring a solution to my needs, and that you were
willing to be flexible in your approach to help me.

You did warn me that the impact of Mindfulness could be life
changing, and I am delighted to say that you were right. It has allowed
me to understand myself in a way that I had never imagined. It has given
a way of living with myself, and the consequence of that is that I am no
longer "beating myself up" about my reactions to situations no
longer despairing at myself for feeling a certain way.

The focus on living in the present is very important to me. I had
already learned from our counselling that I had a propensity to either
be constrained by the past repeating itself; or by my forecasting
pessimistically about the future. Very often this meant that I was not
allowing myself to enjoy what I was actually doing in the present, and
what is more, I think that deep down I recognized this problem, which
made me feel worse about myself. To be able to bring myself back in the
present has been a liberating and uplifting feeling for me.

Mindfulness has given me the ability to create just enough space
between me and thoughts/feelings to be able to recognize them, and the
combination of the space and recognition has allowed me to either simply
accept them and move on, or it has enabled me to take action in order to
support myself, as a step towards moving on.

It is not just my life that has been improved by Mindfulness, but
those around me. My wife in particular, and also work colleagues, have
all remarked directly or indirectly how much lighter and happier I have
become. I can feel it in their responses to me, and that in turn, has an
encouraging and uplifting feeling for me.

Most importantly, Mindfulness is providing me with a tool for the
remainder of my life. At some stage, the counselling will stop, but
Mindfulness will continue.

For me, the counselling experience and the Mindfulness has actually
become a benefit--a positive to emerge from the lowest point in my life.
Losing (baby's name) and then the experience of becoming depressed
have been horrendous, but nevertheless, it does now feel incredibly that
something good has emerged that will make the rest of life better.'

John was with me in therapy for just over two years. It is now two
years since the end of therapy. A year ago, I was delighted to hear from
him. He wrote, 'I am well. Mindfulness would certainly be useful
for my colleagues right now!' (He was referring to colleagues in
the financial sector during the economic downturn).

Conclusion

This paper highlights the theoretical rationale of how Mindfulness
helps in the prevention of relapse of depression in Mindfulness Based
Cognitive Therapy (MBCT) and how I see the applicability of bringing
together insights from MBSR/MBCT albeit with many adaptations to
flexibly integrate Mindfulness with Existential therapy as Mindfulness
Based Existential Therapy (MBET). The integration for me is seamless
within my own being. I consider the therapeutic relationship as central
to our work with clients in therapy. It is within the centrality of the
therapeutic relationship that Mindfulness is offered, as I allow myself
to be informed of valuable research from MBCT.

Contrary to the position of many Existential therapists, I am not
averse to introducing the 'technique' of Mindfulness in my
therapy work. Had I not introduced mindfulness, perhaps John may have
still been helped. However, by not offering mindfulness, I would have
denied him the benefit of research knowingly, and that doesn't sit
well with me. Nor would I have ever known its possibilities for John.

It is my view that perhaps, we as Existential therapists need to
re-think what we mean by 'techniques'. Every training requires
some methods. Psychoanalysis utilises the method of free- association
and evenly hovering attention to offer a non -judgmental space in which
all thoughts, feelings, emotions can be expressed. Existential therapy
offers the rules of horizontalisation, description, epoche in the
phenomenological method of enquiry. If Mindfulness offers
'techniques' to cultivate acceptance, loving-kindness,
compassion, spacious awareness, and presence, I wonder why we as
Existential therapists are so averse to including it as a practice and
in our training programmes?

Mindfulness Based Existential Therapy (MBET) is part of who I am,
as both Mindfulness and Existential therapy are integrated within my own
being, and remain in process... While I offer Mindfulness only as an
option to therapy clients, many clients who now approach me do so as
they are interested in both mindfulness and therapy. Mindfulness Based
Existential Therapy (MBET) is now part of the paid session.

Significantly, I would like to stress, the therapist's
embodied stance of 'being with' and 'openness' to
the client's lived experience is the crucible within which
Mindfulness practice is offered. I sit with Shunryu Suzuki's words,
'In the beginner's mind there are many possibilities, but in
the expert's there are few' (Suzuki, 1970, p21).

Gendlin, E. (2003). Beyond postmodernism: From concepts through
experiencing. In Frie, R. (ed) Understanding Experience: Psychotherapy
and Postmodernism. London and New York: Routledge.

Gendlin, E.T. (2007, June). Focusing: The body speaks from the
inside. [Transcript of talk given at the 18th Annual International
Trauma Conference, Boston, MA]. New York: The Focusing Institute.
http://www.focusing.org/gendlin/gol_all_index.asp.

Germer, C.K. (2005). Mindfulness what is it? What does it matter?
In Germer, C.K, Siegel, R.D. and Fulton, P.R. (ed) Mindfulness and
Psychotherapy. New York: The Guilford Press.

Jyoti Nanda CPsychol is registered as a BPS/HPC Chartered
Counselling Psychologist, UKCP Existential Psychotherapist, and is MBCAP
accredited. She is a Visiting Lecturer at Regent's College School
of Psychotherapy and Counselling Psychology, London, where she teaches
on the Doctoral Programme in Counselling Psychology. She has studied in
India, the UK, and USA, and has travelled widely. Her clinical
experience includes working with patients in an NHS hospital and in
Private Practice. A long term practitioner of meditation in more than
one tradition, Jyoti's research interests are centred on
meditation, mindfulness and its effect on the therapeutic relationship,
and cross-cultural therapy. She conducts workshops and short courses on
mindfulness and its relationship to psychotherapy in general, with an
emphasis on the co-created relational stance that underpins Existential
therapy in particular.